Grievances and Appeals Coordinator

The Grievances and Appeals Coordinator processes, tracks and follows up on all medical necessity and administrative denials and appeals for Medicare Advantage members in accordance with Medicare guidelines and regulations. The Grievances and Appeals Coordinator is a critical team player who works in a fast-paced, ever-changing environment with a passionate team and must deliver daily.

QUALIFICATIONS

Successfully completed college courses in relevant field to compensate for experience preferred. Experience: Minimum (3) three years’ health plan experience, compliance and/or quality assurance preferred. Grievance and appeals experience preferred, specifically within a Medicare and/or Medicare Advantage context. Knowledge of NCQA, HEDIS or general accreditation requirements and guidelines for utilization management, denials and appeals.

Familiarity with Appeals processes and regulatory requirements related to appeals.

Benefits

Overview Competitive Pay Rates Affordable Medical Insurance Dental, and Vision Insurance Offered as well as supplemental plans Employer paid Life Insurance Opportunity for CEU Reimbursement 401K offered Description of Required Duties and Tasks: Essential duties and responsibilities include the following. Capture, investigate and respond to all complaints regarding customer grievances and appeals involving provision of service and benefit coverage issues.

Conduct pertinent research to evaluate, answer, and close appeals. Ensure appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs; ensure appropriateness of the response in compliance with State and Federal guidelines.

Assist members when filing appeals; educate member, document and route the information appropriately. Prepare response letters, notifications, and acknowledgements for members and provider complaints, grievances and appeals. Maintain grievance information and supporting documentation in accordance with all state, federal, NCQA, URAC and other regulatory agency standards / regulations.

Escalate issues appropriately or work with other departments to resolve member issues. Ensure all HIPAA and State requirements/regulations are adhered to at all times. Identify issues and root causes of appeals and disputes for plan management and compliance. Identify and report trends and/or areas of opportunities to supervisor.

Maintain and update appeal and grievance policies and procedures, member correspondence materials, and process manuals. Perform internal audits of grievance and appeals process. Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility. Meet or exceed the dress code of the facility as specified in the Employee Handbook, which includes neat, clean, odor-free grooming and dress.

Encourage an atmosphere of optimism, warmth and interest in patients’ personal and health care needs.

Required Skills

Meet critical time frames on a frequent and regular basis Excellent communication skills and active listening Positive, engaging customer service skills Critical thinking and decision-making Work cooperatively with internal departments and external stakeholders Perform in potentially stressful situations, such as state, federal, NCQA, URAC or other regulatory/accrediting agency audits American Health Plans, Inc.

is an EQUAL OPPORTUNITY EMPLOYER